Carol Watkins is a board certified psychiatrist. She has written numerous articles on the treatment of anxiety disorders in children and adults, and maintains a website on anxiety issues.
David Roberts: HealthyPlace.com moderator.
The people in blue are audience members.
David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Anxiety and OCD Medications." Our guest is psychiatrist, Carol Watkins, who is board certified in adult and child psychiatry. She is a clinical assistant professor of psychiatry at the University of Maryland and maintains a private practice in Baltimore, Maryland. She is the author of many published psychiatric papers and a frequent lecturer at workshops and seminars. Dr. Watkins has also written numerous articles on the treatment of anxiety disorders in children and adults, and maintains an active online resource site dealing with anxiety, that you can locate here.
If you are looking for information on a particular medication, you might want to try the HealthyPlace.com psychiatric medications area.
Good evening, Dr. Watkins and welcome to HealthyPlace.com. We appreciate you being our guest tonight. We get a lot of email that goes something like this: "I've tried 3-5 different medications for my anxiety or OCD and nothing seems to work." Why is it that psychiatric medications work for some but not for others?
Dr. Watkins: Each person is different, both in personality and in their individual biochemistry. Some people have different rates of metabolism based on differences in their liver metabolism. On the personality side, people have different attitudes and expectations of medication.
David: What is a reasonable expectation when it comes to the performance of a anti-anxiety medication?
Dr. Watkins: A certain percentage of individuals of each ethnic group may have different enzymes that metabolize a particular medication. It depends on the subtype of anxiety. For OCD, you might expect a 50-70% positive response with medication. Higher, if combined with the appropriate psychotherapy.
David: And for an anxiety disorder or panic attacks, what can one expect?
Dr. Watkins: For panic attacks, I would expect a similar response rate. I often start with smaller medication doses for panic than for Obsessive-Compulsive Disorder. For generalized anxiety, I expect a lower medication response and emphasize therapy in addition to the medication.
David: If you are suffering from an anxiety disorder, would you recommend medications as a first line of treatment, or would you say to the patient, try therapy first and if that doesn't work, then we'll talk about anti-anxiety medications?
Dr. Watkins: It depends on the situation. For adults, I discuss both options. If the symptoms are mild, I am more likely to go with therapy first. If severe, I often recommend starting with medication and therapy simultaneously. For children, I am more likely to recommend a course of therapy first. However, in some cases, if the anxiety symptoms are pervasive, or if the child refuses therapy, I might start medication right away.
David: I know you are a psychiatrist, but I'm wondering what your thoughts are about a person going to see their family doctor and having that doctor dispense medications for their anxiety disorder versus seeing a psychiatrist to be treated?
Dr. Watkins: In some cases, there are primary care physicians who know the patient well, maybe for decades. The physician might know and treat the family too. If the doctor has the time and expertise, then it is OK. If the doctor is busy and can only allot a few minutes, it is better to refer. If the person does not respond well to the first treatment, then a referral is also a good idea. I deal with some primary care physicians who know me and have a good sense of when to refer on to a psychiatrist.
David: We have a lot of questions, Dr. Watkins, and then we'll continue with our conversation.
Sharon1: How do you feel about Serzone as a treatment for panic disorder?
Dr. Watkins: I prefer to start with a SSRI, such as Zoloft (Sertraline) or Luvox (Fluvoxamine) and reserve Serzone if the person has side effects on a SSRI.
sadsurfer: What do you think of alternative medicine, such as acupuncture or massage therapy alone to reduce anxiety if one wishes to come off medication?
Dr. Watkins: Some people get good results with acupuncture. One should also realize that many people get good results with cognitive behavioral therapy or hypnosis without using medications at all.
David: So are you saying that hypnosis and acupuncture are legitimate treatments for anxiety disorders?
Dr. Watkins: I believe that hypnosis, cognitive behavioral therapy and some other forms of therapy are legitimate. I am not an acupuncturist, but I have seen some good results. I do get concerned when some acupuncturists go on to prescribe herbal preparations without checking with me to make sure that they are not interacting with my medications. This can be dangerous.
auburn53: Can hypnosis work by using tapes or do you think you need to have it done in an office?
Dr. Watkins: Some people get good results with the tapes. I prefer to do it in my office to see what technique works best and then make the person a custom tape. It is best though if the person can do self-hypnosis without a tape. More portable.
ninas: Hi David. Is there any way to wean off Clonazepam? Why are my panic attacks cyclical?
Dr. Watkins: If you go off the Clonazepam (Klonopin), do it gradually and with medical supervision. It may take a few months if you are on a large dose. Substitute something else like another class of medication or a form of psychotherapy to get you through.
David: What side effects can one expect if they suddenly decide to withdraw from some of these medications?
Dr. Watkins: Don't suddenly go off a Benzodiazepine (Klonopin (Clonazepam), Valium (Diazepam), Xanax (Alprazolam), Ativan (Lorazepam) etc.). You could get seizures or maybe just feel jittery and anxious. A slow taper is a good idea especially if you have medical conditions or are on other medications.
LISA R: I've been given Topamax for Panic Disorder; however, I've yet to find anyone taking this medication for Panic Disorder. Is this a commonly prescribed medication?
Dr. Watkins: I have never used it for Panic. I have heard of it as an adjunct for Bipolar Disorder.
GreenYellow4Ever: What benefit do you see in making a combo of anti-depressant and anti-anxiety medication?
Dr. Watkins: I prefer to use an SSRI medication such as Zoloft or a medication such as Effexor XR (Venlafaxine). If the person needs something immediate, I will start a Benzodiazepine until the SSRI kicks in. I may also add a benzodiazepine (Klonopin, Xanax etc.) in cases where the first-line drugs do not work completely.
madi: I just had my Prozac dosage raised and it seems like I am going through side-effects again. Is that possible? It seems like the OCD symptoms are worse because I feel so hyper.
Dr. Watkins: Some people can get a restless feeling, called Akathesia from SSRI medications such as Prozac. I have seen it more in Prozac because it is a little more stimulating than some of the other medications in its class. You might talk to your doctor about a switch to another SSRI medication, or you might back off the dose. Sometimes a low dose of a beta blocker (Propranolol, Atenolol) can block the jittery feeling.
David: A site note: We've had a lot of great guests at our chat conferences. You can read the Anxiety and OCD transcripts.
Kerri20: What happens when someone can not take medication due to bad side-effects or even allergic reactions, but therapy is just not enough?
Dr. Watkins: Sometimes, you might start back on medication at a very low dose. I see a lot of people who are sensitive to medications. I use a lot of liquid SSRI medications. Then I go up slowly. I once tasted several of them for the benefit of my pediatric patients. Taste matters to that group. Liquid Paxil tastes best. I haven't tried liquid Zoloft yet. If the jitters bother you, a beta blocker, or a Benzodiazepine might help.
vcarmody:Q: Please speak to significance of Clomipramine at 25mg on a twelve year old child. How significant a dose in suggesting severity of OCD?
Dr. Watkins: I don't always see a correlation between dosage requirements and severity of the disorder. I measure it based on improvement and side effects. Often that would be a low dose, but I don't know if the child is a slow metabolizer.
flowerchild: What is a good medication for panic disorder for someone who is sensitive to meds?
Dr. Watkins: It would depend on the nature of the sensitivity. I sometimes use Zoloft in low doses for adults. In children, I often start with Luvox.
ponder8n: I've read that Benzos can become addictive very quickly. Any comments?
Dr. Watkins: Not always. I am probably more stingy with Benzodiazepines than some of my colleagues. If a person has a tendency toward addiction, I am more cautious of the Benzos. However, I have some people on them who do not display the psychological characteristics of addictions. It depends on how and why you prescribe the Benzodiazepines. If you use them cautiously and do not continuously bump up the dose, they can work well.
David: Some of the medications, like Prozac, that are being mentioned are for depression. And some members of our audience would like you to talk about the connection between anxiety, OCD and depression.
Dr. Watkins: Medications like Prozac and the other SSRIs do help with depression and anxiety and OCD. These disorders are separate entities and may be inherited separately. However, anxious individuals are more likely to get depressed and vice-versa. Often people who have had an anxiety disorder (especially untreated) for a long time, go on to develop depression. In children, I sometimes see anxiety earlier than depression but not always.
Dugan: Dr. Watkins, I am currently taking Celexa, Buspar and am coming off of Paxil because of weight gain. Does this combination of medications have a good success rate for Obsessive-Compulsive Disorder?
Dr. Watkins: Yes, they can work well for OCD symptoms, but you can get weight gain on Celexa (Citalopram) too. Exercise helps with the weight and improves anxiety symptoms too.
madi: Do vitamins have any effects when mixed with OCD medications such as Prozac?
Dr. Watkins: I have not seen any controlled studies (compared to placebo with carefully selected subjects) that show a consistent effect. A balanced diet, at least three meals a day and regular exercise do help.
hobster: If you were treating a patient who is housebound, with some form of OCD with an eating problem, would you recommend medication, cognitive behavioral therapy, or would you recommend Seroxat?
Dr. Watkins: I do not know what Seroxat is. I would recommend CBT and an SSRI. I might also start a Behzodiazepine. Housebound patients may need a couple of home visits from the doctor or a treatment outreach person until they can get into the clinic. For treatment resistant anxiety I may augment a SSRI with Lithium, Depakote, or I may use a beta blocker such as Propranolol. MAO Inhibitors such as Parnate and Nardil can be quite effective, but you need to be on a special diet and they can lead to weight gain. They are probably underused. I don't combine the MAOI with other medications in most cases.
David: Just to clarify hobster's question before, Seroxat is the UK name for Paxil.
Kerri20: I did cognitive behavioral therapy and exposure therapy for about three weeks and I found it was working great. I noticed I went down hill after stopping therapy. I guess I want to know what is the average length of time that someone would be in therapy to get the best out of it, or to keep it up, so to speak.
Dr. Watkins: You can have relapses after stopping either therapy or medication. The time frame varies. I usually recommend follow up therapy sessions as "boosters." When I stop the active phase of treatment, I have the patient and often a significant other write down the early warning symptoms. We make plans for what we will do if it starts to come back (anxiety disorder relapses). We write these down and everyone has a copy. Same process for coming off medications.
Cortny9: I am nine years old and I take Zoloft. It has helped me a lot. But my mom and I would like to know if there are long term side-effects?
Dr. Watkins: Paxil is a good SSRI to use for a patient with OCD. We don't have a lot of long term data on Paxil in children. However, physicians are supposed to send in reports of problems with medications. I haven't seen severe long-term side-effect reports.
Brin: Should a nine year old be on Zoloft?
Dr. Watkins: Zoloft can be used in children that age with OCD. Each case is individual. I look at a variety of treatment options in a child with OCD. There is a great book, "Blink, Blink, Clop Clop, Why Do We Do Things We Can't Stop?" that explains OCD to children.
David: You can visit the HealthyPlace.com psychiatric medications area, if you are looking for information on a particular medication.
tracy565: Do people with panic disorder need to be on medication all their lives?
Dr. Watkins: Not necessarily. Some people learn techniques to deal with the symptoms. I will taper it in some people and have them step up their therapy while we do the taper.
sgroove63: I've been on Serzone for anxiety and anorexia and bulimia for about a month (up to 200mg). I have had strange side effects. I'm dizzy, spacey, silly, and have a lack of coordination. How serious are these? My psychiatrist also started me on a small dose of Celexa a week ago, I think in anticipation that the Serzone won't work for me. What do you think?
Dr. Watkins: I have had several people who have had those types of symptoms on Serzone. Often, they are the same people who have trouble on Prozac. Celexa might be a good substitute for the Serzone. Ask your doctor if she is planning a substitution or if she intends to keep you on both. You need to use caution if you combine the two.
David: Why, what can happen?
Dr. Watkins: Sometimes, when you use two different medications that act on Serotonin, you can get a buildup of the Serotonin. This can occasionally lead to Serotonin Syndrome, one might get a bit disoriented.
Dr. Watkins: St. Johns Wort, combined with some medications can cause serotonin syndrome too.
Jitterbug: I have recently found that I have severe OCD and I don't like medication. However, I took the advice of my therapist and went on Zoloft. I then heard about Luvox and I was wondering which medication is better for OCD. I am having the hardest time functioning everyday. I'm feeling depressed and need something to help.
Dr. Watkins: Is your therapist also your psychiatrist? I am not keen on non-medical therapists recommending medication, unless the therapist is in very close contact with your psychiatrist. One is not necessarily better than the other. Luvox can interact with some other medications, so I tend to use it more by itself. I like it with children. Celexa may be less likely to interact if you are on a lot of different medications.
btlbaily: I have been on Zoloft for about six months. If I decide to get pregnant, is it recommended to discontinue the medication? And, if so, how long does it take to "wean" yourself off the medication?
Dr. Watkins: Some women do take Zoloft and Prozac during pregnancy, without problems. You need to discuss this with both your psychiatrist and your OB/GYN prior to conception. You should have your medications prescribed by a psychiatrist who is familiar with this sort of thing and who is willing to keep in touch with your OB. You need to go over the risks and benefits of taking the medication and the risks and benefits of going off medication.
pavanne: What is your opinion of using Buspar instead of Zanax and the like?
Dr. Watkins: BuSpar is less likely to be addictive. However, it takes longer to kick in. If I need something to work really fast, I would go with a Benzodiazepine. However, I like to consider SSRI medications first.
David: Roughly, how long does it take for a medication to be effective?
Dr. Watkins: A Benzodiazepine can be effective in a matter of minutes or hours. An SSRI such as Zoloft or Prozac may take longer (a week to six weeks). BuSpar takes several weeks. A beta blocker may take effect fast, but mostly just covers the external manifestations of anxiety, such as tremor and palpitations. People with stage fright sometimes take a small dose of a beta blocker before a performance to block the tremulousness. If they can control that external part, they may be able to manage the internal feelings.
murkyangel: I've tried over ten medications: Serezone, Welbutrin, Effexor, Trazadone, Buspar, Remeron, Depakote, Zanax, and am currently on 450mg Welbutrin (again), 1mg Risperdal, and usually 10mg valium a day. It's better than no meds, but not really taking away the anxiety during the day (I take the valium at night). Anyway, what else do you suggest? And yes, I've tried therapy and groups and all that other stuff). I'm at my end in all of this and I don't know what to try next. I've tried many combinations of those medications that I listed.
Dr. Watkins: It is difficult to say. It would depend on the subtype of anxiety. It would also be useful to find out what relatives have taken and what helped them. A MAOI such as Parnate or Nardil might be a consideration. You would need to discuss this with your psychiatrist and get counseling about the MAOI diet. No beer, aged cheese and several other things.
terrjohn: Does a person have to be weaned off of Paxil? My doctor just changed my meds.
Dr. Watkins: Some people who stop Paxil suddenly, feel like they have the flu. It feels uncomfortable for some people. Same for Effexor.
terrjohn: How well does Wellbutrin work compared to Paxil for panic and anxiety disorder?
Dr. Watkins: I think that Paxil would generally be a better choice. Wellbutrin is a great medication for some depression and can also help ADHD, but is not as good for panic. I have occasionally seen it make panic worse. I might add Wellbutrin to an SSRI if the person's anxiety was better, but he or she was still depressed and lethargic. I might also add it to help with sexual dysfunction associated with an SSRI.
Veralyn: I am on Paxil and I was on Prozac a few years ago. I have both depression and anxiety with it. What is the difference between Paxil and Prozac?
Dr. Watkins: They are both selective serotonin reuptake inhibitors. (SSRIs). They have the effect of increasing the availability of serotonin between nerve synapses. Prozac tends to be more stimulating and lasts longer. Paxil is likely to be more sedating and wears off quicker. When you stop Prozac, it stays in your system for weeks or more and gradually goes out. Paxil goes out faster. That is why you may need to taper Paxil but not Prozac. A few people get sleepy on Prozac and are more alert on Paxil but they are in the minority.
David: Thank you, Dr. Watkins, for being our guest tonight and for sharing this information with us. We will see you tomorrow night to talk about "Bipolar and Depression Medications". Dr. Watkin's website is here.
And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have very large Anxiety and OCD communities here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others, http://www.healthyplace.com.
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We've had a lot of great guests at our chat conferences. You can read the Anxiety and OCD transcripts on our site.
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Good night everyone.